Intro: Duly Noted, a health and care podcast, is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners reimagine and better understand an extraordinary health and care experience.

Joey Wahler (Host): It's a means of addressing imperfections in our skin, so we're discussing Fraxel laser treatment. Our guest, Dr. Alix Charles. He's a Dermatologist and Chairman of the Dermatology Department at Duly Health and Care. This is Duly Noted, a health and care podcast. Thanks for listening. I'm Joey Wahler. Hi, Dr. Charles. Thanks for joining us.

Alix Charles, MD, FAAD: Hey there, thank you for having me.

Host: Great to have you aboard. So first, in a nutshell, we'll get into details in a moment, of course, what are Fraxel lasers and how do they work?

Alix Charles, MD, FAAD: So, I think it's always useful when talking about lasers to give lay people even a little bit of background and lasers sound like they would be complicated to understand, but I think I can try to break it down more easily for the listener so they can better evaluate lasers themselves in the future and about how they would want to approach if they want to get a laser procedure.

So, a laser is essentially a light based device, and it uses light that gets excited so that you add energy to this light. Now, just like when you're walking around everywhere, you use light to be able to see around you and to detect colors around you; lasers, in general, are attracted to one color or another.

Some lasers are attracted to the color red and are useful for red things on people's bodies, like red broken blood vessels. Other lasers are attracted to things that are dark, like the darkness of hair. So you could use those lasers potentially for laser hair removal. So, a laser that's attracted to a certain color will try to deposit all of its excited energy into whatever is that color, which heats that thing up and destroys it.

So if you use a laser that's attracted to tattoo ink, it will try to deposit its energy in the tattoo ink and destroy the tattoo ink and hopefully destroy that unwanted tattoo as well. So Fraxel lasers and Fraxel is a name brand, by a company called Solta. They own the Fraxel brand of lasers.

Fraxel lasers are an interesting form of a laser because these lasers are not actually attracted to a certain color, but rather they are attracted to water and water in the skin. You can use a Fraxel laser to target and excite the water in a person's skin at different levels superficially or maybe even a little bit more deeply and by exciting the water within the skin, you can achieve a certain result, that we'll talk about some of the things that Fraxel lasers can do.

Now, a Fraxel laser is special in that it will fire its laser energy off in a sort of what I call a window mesh pattern. So a lot of little pixels, a lot of little tiny holes in what we call a fractionated way. So most lasers are just one continuous beam and they just go after everything where the beam is, but Fraxel lasers are special.

They use lots of little tiny beams, almost like window mesh. So when it affects the skin in that window mesh pattern, you have areas of skin that have been treated by the laser and areas that have not been treated by the laser, the untreated areas of skin are able to help the treated areas of the skin to heal, because they're right next to each other with this window mesh pattern.

And that really has revolutionized and shortened the amount of healing time that's required for some lasers and Fraxel really takes advantage of this particular benefit.

Host: So we'll talk in a moment about what skin conditions these lasers address, but you mentioned, some of what goes into the treatment. How does that compare with other prior, longer existing laser skin treatments?

Alix Charles, MD, FAAD: For some of the indications that we're going to talk about for Fraxel, and by indication, I mean disease states or things that we would treat with a Fraxel laser. For some of the indications, we used to use older technology instead of using a fractionated or window, mesh window screen, sort of approach.

They used what they call continuous wave. So you would use lasers that would also target water that would excite water in the skin. But instead of doing it in a window mesh pattern, it would just go after all the skin in a certain section, say a one centimeter by one centimeter section, just getting rid of all the skin and getting rid of all the layers of the skin at the same time.

This is a lot of tissue damage and in a controlled way, if it was used by somebody with the right training and the right vision, then they could accomplish some pretty remarkable things in terms of clearing up complexion and helping to rejuvenate the skin and make people look younger. But the trade off was the downtime because patients would have almost a burn like effect over all of their skin. The complication rate was higher. There was a higher risk of patients having pain, and prolonged pain, having infections and having scar formation. These Fraxel lasers are different from the continuous wave lasers that do still exist, by the way, because there's still a role for continuous wave lasers; but Fraxel lasers are different in that this window mesh pattern that boosts healing in the areas that have not been treated by the little beams of the laser, really can help a patient heal and it really reduces the risk of pain, of infection, of scar formation and the like.

Host: Gotcha. As mentioned, what skin conditions are we talking about here? And it's not just the face, right? It's other parts of the body as well. Am I right? Cause I think you'd agree, Doc, most people, lay people tend to think of skin issues as being on or around the face primarily, but that's not always the case.

Alix Charles, MD, FAAD: That's correct. The Fraxel laser actually can be used on other body parts, although I will say that the main area we target is the face. The Fraxel laser itself is actually a, has two laser wavelengths in one platform. The individual, the dermatologist or the physician who's operating the laser can choose to use one wavelength at a time, if that's what they want to do, or they can use both wavelengths.

One of the wavelengths is more superficial and is primarily suited to treating things that are brown. So it's mainly used to rejuvenate skin that is brown because it has condition like melasma or it's brown from chronic cumulative sun exposure. Or maybe the person's skin is brown because of some kind of an injury, maybe they had acne, and the acne left brown marks in the skin, which is especially true for people with richly pigmented skin Latin and African descent.

The second wavelength that the Fraxel laser has that can be used along with this more superficial one, is a deeper wavelength and deeper kind of to where pore texture irregularities lie. And so this, other laser wavelengths can be used to target pore texture, dull texture, fine lines and wrinkles.

It can be used to tighten the skin around the eyes or around the mouth. All of these lasers, both laser wavelengths, can also be used off the face. They can be used on the neck. I've used them successfully on the chest for patients, on their arms, and on their hands. Most of the time, people use them in areas that will be mostly visible for others to see, so not a lot of people are using the Fraxel laser on their lower back or their abdomen.

The face is still the number one area that it's used, with the neck following up after that. But we do a lot of forearm work and a lot of work on the hands as well because people have become savvy to the fact that if they only take care of their face and make their face look its best and look its youngest, if they don't take care of their hands, then people can see that contrast, that disconnect between the way their face and their hands look.

Host: Interesting. I didn't know that some people were walking around seeing if someone's hands matched their face and their neck, but I guess in some cases it sounds like that's true. So what should patients, Doctor, expect during a Fraxel laser treatment? What goes on?

Alix Charles, MD, FAAD: Sure. So the treatment itself begins, prior to even the treatment, you'd have a consultation with a physician who would talk to you about why you might want to consider the Fraxel or why you might be an appropriate candidate for the Fraxel. They talk about your past medical history, about your history of having had other cosmetic procedures, perhaps injectables or perhaps other laser procedures, and how those things have gone for you.

And they'll discuss with you if you're taking any medications or undergoing any treatments that might complicate the results of a Fraxel laser treatment, just to make sure that you're an appropriate candidate. I will say that this laser is essentially what we would call color blind. So although when you are using lasers in general, I tell people you've got to be very careful with skin of color.

It's less forgiving when you use lasers on it, certain lasers at least. This laser is unique in that it's colorblind, so anyone with, from somebody with very, very fair skin to somebody with a really dark skin can be treated with this laser safely, provided the operator knows the safe settings and has experience. After we consult with the patient, decide that they're going to be a candidate, they would come in the day of their treatment. They usually show up early, maybe an hour before the treatment or 40 minutes or so before the treatment so that we can apply a topical anesthetic, a topical numbing cream to the skin of their face and then they'll lay there, doing Wordle or reading something on their phone or maybe listening to a Duly Noted podcast to kill some time.

Host: Nice plug, by the way.

Alix Charles, MD, FAAD: And while they're laying there, the anesthetic will take effect. And, as the anesthetic takes effect, finally, we, the staff, waits about half an hour or so, and then we'll come in, we'll wipe off the anesthetic, and then go ahead and immediately begin to use the laser treatment. To make patients even more comfortable, we oftentimes, there's a special cooling applicator that's attached to the laser that blows cold air right at the area where the laser is passing.

Because, even with anesthetic, you can sometimes still feel the laser pulses a little bit. Feels a little bit like some mosquitoes biting on the skin, I suppose, or it feels like a little bit of prickly, warm heat. So the cold blower, the Zimmerchiller as it's called, can sometimes help to cool the skin off to make it more comfortable.

But the whole procedure doesn't take that long, maybe 20 or 30 minutes, depending on the body part that's treated and how large that body surface area is. As soon as the treatment's done, the patient can expect the treatment area to be a little pink, maybe a little bit swollen, and that might last for about a day or so. With some of the Fraxel lasers, a few days into it, the skin will start to peel and shed almost like a snake. It starts to kind of fall off leaving much more supple and youthful and clearer skin behind. There's not a lot of wound care to do or post laser care. Just sometimes some simple serums and washes and things that you have to apply to the face.

So patients will have some downtime. We tell them that there's mainly some social downtime. You could still hang out with friends who don't mind seeing you look a little pink or a little bit flaky. You just wouldn't want to go on the most important job interview of your life, you know, a few days afterwards, you'd want to give yourself a few more days to recover.

But this procedure doesn't come with very intense recovery, although the results can be pretty amazing. And so that's why it's so popular, and I think it's risen in popularity for that reason as well.

Host: Gotcha. A couple of other things. So how many sessions are typically needed for optimal results and how long do the results typically last?

Alix Charles, MD, FAAD: That's a really good question, and some of that really depends on a lot of factors. One of the main factors being the patient themselves. We see all sorts of patients and all sorts of different patients and people. I've seen a couple people in the past who had just minor, light amounts of brown discoloration on their skin, and I told them, hey, I could probably do one treatment session, you'll, you'll be okay for a while.

There are other people, I'll take a look at them and say you know, you've got definitely more sun damage and more sun induced pigmentation than some other patients, and you might require two or maybe even three sessions of this laser treatment to achieve the results that we would want. For almost any of the indications that involve improving texture and tone and getting rid of fine lines and wrinkles, it requires multiple treatment sessions, usually a minimum of three, but perhaps as much as even six, to stimulate collagen over time very slowly and achieve the best results possible. When you talk about longevity of the results with the Fraxel laser, I tell patients, well, if you could get the Fraxel laser and then live inside your house and never go out in the sun again, then you'd have longer lasting results, but that's not what happens, practically speaking.

People, of course, go on and live their lives. And so we tell them to cover up, wear hats, wear sunscreen, do the best that they can to protect their investment, knowing that patients will probably still need touch up treatments every couple years of almost any of the Fraxel laser treatments that we perform.

And most patients are really happy to return for a touch up treatment because they get such amazing results that after a year or two or three if they notice that they have some browns coming back or they need a little bit more TLC, they're usually pretty happy to undergo another 20 minute procedure.

Host: So who's an ideal candidate for this treatment and contrastingly, is there anyone that's not a candidate for any reason?

Alix Charles, MD, FAAD: I would say that, first of all, again, it's well suited to almost any skin type. The main patients who I would say are great candidates for this are people who have a mild to moderate amount of sun damage or a mild to moderate amount of melasma. And they have already been using topical skincare products and sunscreens and antioxidants and a lot of the topical cosmeceuticals that we have recommended for them, yet they're still not getting optimal results.

These patients may also be averse to doing more intense laser procedures that would require more downtime. And so they'd like to do a procedure that has a little less downtime, or they're averse to undergoing any kind of an invasive procedure that might help with wrinkles. They don't want injectables or maybe they don't want plastic surgery.

Those sorts of patients are also really great for this. The Fraxel laser is not bad at all for patients who want to prejuvenate. We oftentimes say that these days, a lot of our work is trying to prevent folks who are younger, who are already doing a great job staying out of the sun, but they want to give their skin that extra boost; so as they mature over the decades, they wind up in a better position than their mothers, fathers, and aunts and uncles. And it's great to treat patients in advance, as well, so you're not repairing damage, you're putting more collagen in the bank, so to speak, so that can look better and stay the same looking, possibly youthful looking for extended periods of time.

Now, a patient who is completely pain averse is probably not a good patient for the Fraxel because there's a little bit of discomfort, even with the topical anesthetic cream applied. I don't know, patients who are perhaps completely naive to cosmetic procedures may have a more challenging time jumping into the, the laser pool first.

They might do better with something, a more gentle treatment at first, but sometimes even then, I've seen patients who have been mostly treatment naive do very well with the Fraxel laser if they needed that. If a patient has certain autoimmune conditions or conditions that might make their skin sensitive to light, to sunlight and other forms of light, then they may not be candidates for the Fraxel laser, which is why we pre screen patients and talk to them about these sorts of things when they come in for their initial consultation.

Host: Interesting that you can do it proactively as well, as you pointed out. Finally, in summary here, any risks or side effects associated with these treatments?

Alix Charles, MD, FAAD: I like to tell my patients that all lasers carry essentially the same risks. Pain, burning, blistering, scar formation, changing the pigment of the skin to either increase the pigment or reduce the pigment of the skin, those are the main risks that are inherent in using any kind of laser on anyone's skin.

Now, the difference is, if you go to somebody who's trained and has experience, then you and they have a better chance, a better opportunity that they will select the right laser and use the right energy settings and there's a number of different settings that you have to be aware of to control for, but somebody with experience and talent and knowledge is able to use the right settings to mitigate and reduce those risks for the patient.

You can never completely eliminate those risks. But you can do a lot to mitigate and a lot to reduce those risks. One of the things patients can do themselves during laser procedures, when they're undergoing laser procedures, if they want to reduce those risks, I always tell them is protect from ultraviolet light, protect from sunlight, because sunlight is the enemy of wound healing and sunlight is the enemy of skin recovering from a laser procedure.

Enough so much so, I would say that here in Midwest where most of our Duly offices are located. Here in the Midwest, our dermatology offices do a lot more laser procedures in the fall and in the winter than we do, say, in the late spring or in the summer. Because those times of the year, it's just more challenging for patients to avoid the sun and to consistently photo protect, given that they're involved in different activities, going out to barbecues, hanging out on boats and beaches and lake houses.

So we tell patients that if you really want to undergo a procedure like this, the winter is an ideal time to do it because we don't get a lot of sunlight and you can more easily protect yourself from the downside risk of ultraviolet light.

Host: Sounds like great advice as well. Well, folks, we trust you're now more familiar with Fraxel laser treatment. Dr. Alix Charles, thanks so much again.

Alix Charles, MD, FAAD: Absolutely. That was a lot of fun. Thank you for having me.

Host: Same here. And for more information, please visit DulyHealthAndCare.com. Again, that's DulyHealthAndCare.com. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler, and thanks again for listening to Duly Noted, a health and care podcast.